Gallstone Disease

Tips & Tricks in Management

DR.PANKAJ INGALE
M.D. D.N.B.(GASTRO)
CONSULTANT
GASTROENTEROLOGIST
 GALLBLADDER STONES

• SYMPTOMATIC

• ASYMPTOMATIC
 Symptomatic Gallstones

True symptoms of gallstones include Acute

cholecystitis (a febrile illness with pain and
tenderness in the right upper quadrant),
Biliary colic, Obstructive Jaundice (often
painful), and acute Pancreatitis.
 Cholelithiasis

Potential Complications

Cholecystitis Carcinoma
 Acute Pancreatitis
 Recurrent
CBD stones
 Chronic
Cholangitis
Asymptomatic Gallstones
How Are They Detected

 Health Check-up
 US Abdomen
 Family History
 Pre-Employment
 Pregnancy
 Gallstones

 Types of gallstone
 Cholesterol stones (20%)
 Pigment stones (5%)
 Mixed (75%)

 Epidemiology
 Fat, Fair, Female, Fertile, Fourty inaccurate, but reminder
of the typical patient
 F:M = 2:1
 10% of British women in their 40s have gallstones
 Genetic predisposition – ask about family history
 Pathogenesis

• Composition of bile:
• Bilirubin (by-product of haem degradation)
• Cholesterol (kept soluble by bile salts and lecithin)
• Bile salts/acids (cholic acid/chenodeoxycholic acid):
mostly reabsorbed in terminal ileum(entero-hepatic
circulation).
• Lecithin (increases solubility of cholesterol)
• Inorganic salts (sodium bicarbonate to keep bile
alkaline to neutralise gastric acid in duodenum)
• Water (makes up 97% of bile)
 Pathogenesis

 Cholesterol
 Imbalance between bile salts/lecithin and cholesterol allows
cholesterol to precipitate out of solution and form stones
 Pigment
 Occur due to excess of circulating bile pigment (e.g. Heamolytic
anaemia)
 Mixed
 Same pathophysiology as cholesterol stones

 Other Factors
 Stasis (e.g. Pregnancy)
 Ileal dysfunction (prevents re-absorption of bile salts)
 Obesity and hypercholesterolaemia
Complications of Gallstones

• 80% Asymptomatic
• 20% develop complications and do so on
recurrent basis
Complications of Gallstones
Myriad Presentations of Gall Stones
Complications of Gallstones

 Biliary Colic
 Acute Cholecystitis
 Gallbladder Empyema
 Gallbladder gangrene
 Gallbladder perforation
 Obstructive Jaundice
 Ascending Cholangitis
 Pancreatitis
 Gallstone Ileus (rare)
Differential Diagnosis of RUQ
pain

Gallstone disease (and its related

complications)
Gastritis/duodenitis
Peptic ulcer disease/perforated peptic ulcer
Acute pancreatitis
Right lower lobe pneumonia
MI
 Which Gallstone
Complication?
• Can differentiate between gallstone
complications based on:
• History
• Examination
• Blood tests
» FBC
» LFT
» CRP
» Clotting
» Amylase
Complication History Examination Blood tests
Biliary Colic - Intermittent RUQ/epigastric pain -Tender RUQ -WCC (N) CRP (N)
(minutes/hours) into back or right -No peritonism - LFT (N)
shoulder -Murphy’s –
- N&V -Apyrexial, HR and BP (N)
Acute Cholecystitis -Constant RUQ pain into back or -Tender RUQ -WCC and CRP (↑)
right shoulder -Periotnism RUQ (guarding/rebound) -LFT (N or mildly (↑)
-N&V -Murphy’s +
-Feverish -Pyrexia, HR (↑)

Empyema -Constant RUQ pain into back or -Tender RUQ -WCC and CRP (↑)
right shoulder -Peritonism RUQ -LFT (N or mildly (↑)
-N&V -Murphy’s +
-Feverish -Pyrexia, HR (↑), BP (↔ or ↓)
-More septic than acute cholecystitis

Obstructive Jaundice -Yellow discolouration -Jaundiced -WCC and CRP (N)

-Pale stool, dark urine -Non-tender or minimally tender RUQ -LFT: obstructive pattern bili (↑),
-painless or assocaited with mild -No peritonism ALP (↑), GGT (↑), ALT/AST (↔)
RUQ pain -Murphy’s – -INR (↔ or ↑)
-Apyrexial, HR and BP (N)

Ascending Cholangitis Becks triad -Jaundiced -WCC and CRP (↑)

-RUQ pain (constant) -Tender RUQ
-Jaundice -Peritonism RUQ
-Rigors -Spiking high pyrexia (38-39)
-HR (↑), BP (↔ or ↓)
-Can develop septic shock
Acute Pancreatitis -Severe upper abdominal pain -Tender upper abdomen
(constant) into back -Upper abdominal or generalised
-Profuse vomiting peritonism
-Usually apyrexial, HR (↑), BP (↔ or
↓)
Gallstone Ileus - 4 cardinal features of SBO -distended tympanic abdomen
-hyperactive/tinkling bowel sounds
-LFT : obstructive pattern bili (↑),
ALP (↑), GGT (↑), ALT/AST (↔)
-INR (↔ or ↑)
-WCC and CRP (↑)
-LFT: (N) if passed stone or
obstructive pattern ifstone still in
CBD
-Amylase (↑)
-INR/APTT (N) or (↑) if DIC
 Investigations for gallstone
disease
• Bloods (already discussed)
• AXR (10% gallstones are radio-opaque)
• E-CXR (to exclude perforation – MUST!)
• ECG (to exclude MI)
• USS: first line investigation in gallstone disease
• Confirms presence of gallstones
• Gall bladder wall thickness (if thickened suggests cholecystitis)
• Biliary tree calibre (CBD/extrahepatic/intrahepatic) – if dilated suggests stone in CBD (normal CBD <8mm).
• Sometimes CBD stone can be seen.
• MRCP: To visualise biliary tree accurately (much more accurate than USS)
• Diagnostic only but non-invasive
• Look for biliary dilatation and any stones in biliary tree
• ERCP: Diagnostic and therepeutic in biliary obstruction
• Diagnostic and therepeutic but invasive
• Look for biliary tree dilatation and stones in biliary tree
• Stones can be extracted to unobstruct the biliary tree and perform sphincterotomy
• Risk of pancreatitis, duodenal perforation
• PTC
• To unobstruct biliary tree when ERCP has failed
• Invasive – higher complication rate than ERCP
• CT: Not first line investigation. Mainly used if suspicion of gallbladder empyema, gangrene, or perforation
and in acute pancreatitis (USS not good for looking at pancreas)
 Biliary Colic

Pathogenesis
 Stone intermittently obstructing cystic duct (causing
pain) and then dropping back into gallbladder (pain
subsides)

USS confirms presence of gallstones

Treatment
 Analgesia
 Fluid resuscitation if vomiting
 If pain and vomiting subside does not need admitting
 Acute Cholecystitis
Pathogenesis:
• Due to obstruction of cystic duct by gallstone:
• Cystic duct blockage by gallstone
• Obstruction to secretion of bile from gallbladder
• Bile becomes concentrated
• Chemical inflammation initially
• Secondarily infected by organisms released by liver into bile stream

USS confirms diagnosis (gallstones, thickened gallbladder wall, peri-cholecystic fluid)

Complications of acute cholecystitis

• Empyema of gallbaldder
• Gangrene of gallbladder (rare)
• Perforation ofgallbaldder (rare)

Treatment
• Admit for monitoring
• Analgesia
• Clear fluids initially, then build up oral intake as cholecystitis settles
• IVF
• Antibiotics
• 95% settle with above management
• If do not settle then for CT scan
» Empyema  percutaneous drainage
» Gangrene/perforation with generalised peritonitis emergency surgery
 Obstructive Jaundice

Pathogenesis:
• Stone obstructing CBD (bear in mind there are other causes for obstructive jaundice) – danger
is progression to ascending cholangitis.

• USS
• Will confirm gallstones in the gallbladder
• CBD dilatation i.e. >8mm (not always!)
• May visualise stone in CBD (most often does not)
• MRCP
• In cases where suspect stone in CBD but USS indeterminate
• E.g.1 obstructive LFTs but USS shows no biliary dilatation and no stone in CBD
• E.g. 2 normal LFTS but USS shows biliary dilatation
• ERCP
• If confirmed stone in CBD on USS or MRCP proceed to ERCP which will confirm this (diagnostic) and
allow extraction of stones and sphincterotomy (therepeutic)

Treatment
• Must unobstruct biliary tree with ERCP to prevent progression to ascending cholangitis
• Whilst awaiting ERCP monitor for signs of sepsis suggestive of cholangitis
 Ascending Cholangitis

Pathogenesis:
 Stone obstructing CBD with infection/pus proximal to the
blockage

Treatment
 ABC
 Fluid resuscitation (clear fuids and IVF, catheter)
 Antibiotics (Augmentin)
 HDU/ITU if unwell/septic shock
 Pus must be drained* - this is done by decompressing the
biliary tree
 Urgent ERCP
 Urgent PTC – if ERCP unavailable or unsuccesful
 Acute Pancreatitis

Pathogenesis
• Obstruction of pancreatic outflow
• Pancreatic enzymes activated within pancreas
• Pancreatic auto-digestion

USS: to confirm gallstones as cause of pancreatitis

• USS not good for visualising pancreas

CT: gold standard for assessing pancreas.

• Performed if failing to settle with conservative management to look for complications such as pancreatic
necrosis

Treatment
• Analgesia
• Fluid resuscitation
• Pancreatic rest – clear fluids initially
• Identify underlying cause of pancreatitis

• 95% settle with above conservative management

• 5% who do no settle or deteriorate need CT scan to look for pancreatic necrosis
 Gallstone ileus

Pathogenesis:
• Gallstone causing small bowel obstruction (usually obstructs in terminal ileum)
• Gallstone enters small bowel via cholecysto-duodenal fistula (not via CBD)

AXR – dilated small bowel loops

• May see stone if radio-opaque

Treatment
• NBM
• Fluid resuscitation + catheter
• NG tube
• Analgesia
• Surgery (will not settle with conservative management) – enterotomy + removal of
stone

Diagnosis of gallstone ileus usually made at the time of surgery.

 Cholecystectomy
• Asymptomatic gallstones do not require operation

• Indications
• A single complication of gallstones is an indication for
cholecystectomy (this includes biliary colic)
• After a single complication risk of recurrent complications is high
(and some of these can be life threatening e.g. cholangitis,
pancreatitis)

• Whilst awaiting laparoscopic cholecystectomy

• Low fat diet
• Dissolution therapy (ursodeoxycholic acid) generally useless
 Cholecystectomy

• All performed laparoscopically

• Advantages:
• Less post-op pain
• Shorter hospital stay
• Quicker return to normal activities

• Disadvantages:
• Learning curve
• Inexperience at performing open cholecystectomies
 Cholecystectomy when to
perform?
 After acute cholecystitis, cholecystectomy traditionally performed
after 6 weeks

 Arguments for 6 weeks later

 Laparoscopic dissection more difficult when acutely inflammed
 Surgery not optimal when patient septic/dehydrated
 Logistical difficulties (theatre space, lack of surgeons)

 Arguments for same admission

 Research suggests same admission lap chole as safe as elective chole (conversion to
open maybe higher)
 Waiting increases risk of further attacks/complications which can be life threatening
 Risk of failure of conservative management and development of dangerous
complication such as empyema, gangrene and perforation can be avoided

 National guidelines state any patient with attack of gallstone

pancreatitis should have lap chole within 3 weeks of the attack
 Asymptomatic Gallstones

India

Prevalence : 6% (3% M; 9% F )
West 12-17%
Symptoms : 10-20 %
India : 500 M adults
30 M Gallstones
25 M asymptomatic
Asymptomatic Gallstones

Is treatment indicated ?
Who wants it ?
Outcome ?
 Gallstones: Natural History
123 Michigan faculty - Gallstones on routine screening

On follow-up Became Remained

Symptomatic Asymptomatic

5 years 10% 90%

10 years 15% 85%
15 years 18% 82%

Rate of development of biliary pain is approximately

2% per year for five years and decreases there after
Gracie and Ransohoff. N. Engl. J. Med. 1982
 Asymptomatic Gallstones
Natural History (n=118)
On Follow-up
2 years 12 %
4 years 17 %
10 years 26 % Developed biliary colic

Cumulative biliary complication rate was 3% at ten years

GREPCO Group. Hepatology 1995

 Natural History

 Latent Period : 8 Yrs (Mok, NEJM, 1986)

 2% symptoms per year ; most by 5 yrs

 Prior symptoms before complications

 Some patients (age) never have symptoms

 CA GB rarely detected on follow up

 FU : 38%  Size; 18%  Size

 CA GB
 1-2 % of patients with stones develop CA

 High rate : Native Americans, Chileans, Bolivians

: North Indians : Gangetic Belt

 Race
 Duration of gallstones
 Typhoid carrier stage
 AJPBD

Case control Studies

JNCI, 1985, Cancer 1988

 CA GB

RACE CA GB / Lac No. of Chole to prevent 1 CA

Black 3.0 667

Caucasian 11.5 200

Pima Indians 46.0 67

( Weller : GCNA 1991 )

 CA GB : India

Bangalore : 0.3 - 0.9

Mumbai : 1.9 - 2.4

Delhi : 3.7 - 9.4

Bhopal : 1.1 - 4.2

ICMR , 1995 : AAR PER 105

Gallstones Increased Risk of Ca.

 > 3cms Diameter (risk 10 fold)

 Certain Populations (Chileans, Pima Indians)
 ? Difference between South Vs North

67 Cholecystectomies to prevent in one

high risk case
 Asymptomatic Cholelithiasis
Risk of GB Cancer

 80% of GB Carcinomas have GB Stones

 2583 GB calculi  5% Ca.(0.2%)
Ann Ind Med 1987

 769 Cholecystectomies to prevent one Ca.

Asymptomatic Gallstones : Who’s at Risk

Porcelain GB : 20-60% CA
Renal Tx : 18% require Surgery
Abd Sx : 37-45% Symptoms
Vascular Sx : 25-50%

Diabetes : 15% 5 Yrs

Size ; No. ; Func. GB
 Asymptomatic Cholelithiasis
Diabetes

 Natural history of gallstones in diabetics

follows the same pattern
observed in non-diabetics
 Prophylactic cholecystectomy is
generally not recommended
 Decision Analysis
Prophylactic Cholecystectomy
 Prevent Symptoms
 Prevent Complications
 Prevent CA GB

Expectant management
 Surgery cost
 Surgical complications avoided

(Ann Int Med 1983 ; Ransohoff, Gracie)

 Decision Analysis

 Cholecystectomy does not add to life

expectancy

 Cost $ 4000 Vs $ 660 for expectant mgt

( for a 30 Yrs old )

( ANN Int Med 1983 )

 Asymptomatic Cholelithiasis

 Elderly Patients in South India 

Leave it alone

 Young Patients in North India 

Take it out
 To Answer This Question
Prospective Trial Needed
Asymptomatic GB Calculi

Prophylactic Surgery Observation

 Risk of Complications  Risk of Symptoms

 Economic Implications  Economic Implication
 Asymptomatic Cholelithiasis
Prophylactic cholecystectomy – Indications

Definitive Relative
 Porcelain gallbladder  Life Expectancy >20Yrs.
 Patient with sickle cell  Calculi >2cms or <3mm
anemia (with patent cystic duct)
 Patient awaiting  Radio-opaque calculi
transplant  Non-functioning GB
 Prolonged extremely
 Concomitant Diabetes
remote assignments
Patino et al.. WJS, 1998
Evidence : Leave Them Alone !!!

 At 20 Yr : 65 – 70 % will be asymptomatic
 Warning symptoms ; rarely complications
 Cost analysis & Life expectancy
 CA GB Risk : Poorly understood
Race – Genetics – Environment ?
(Gangetic belt , S Americans)
 Select groups : any abd surgery
• THANKS……
 Asymptomatic Gallstones

Do Asymptomatic Gall Stones

Remain Asymptomatic forever ?
 Asymptomatic Gallstones
Renal / Heart Transplant Patients
ESRD(6) CCC(1)

Those Who Underwent Prophylactic

Lap Chole Fared Better

Prophylactic Lap. Chole – Justified in Preparatory Protocols

Boltri F et al Minerva Chir 1994